Speaker 1 00:00 Rob, welcome to Rosalind Franklin University, College of Pharmacy top 200 drugs podcast. Speaker 2 00:12 This podcast is produced by the pharmacy faculty members to supplement study material for students learning the top 200 drugs we're hoping that our real life clinical pearls and discussions from practicing pharmacists will help you study for your next drug quiz. Speaker 1 00:29 No participants have any conflicts of interest to disclose. This podcast is for educational purposes only and is not intended to treat a particular patient. This information should not be used in lieu of the judgment of a health care provider. Dr. Sean Kane 00:41 This podcast is copyright Rosalind Franklin University of Medicine and Science, and now on to the show. Welcome to Week 10 of Rosalind Franklin University's top 200 drugs podcast. I'm your co host, Dr. Kane. I'm Dr. Patel and I'm Dr. Mitchener, and today we'll be talking about agents for COPD and asthma, Speaker 3 01:01 most of these agents are inhaled. There are several different types of inhalers available, such as metered dose inhaler, which is shortly known as MDI, dry powder inhaler, Handihaler and nebulizer solutions. However, certain products have oral formulations, such as tablets and solution available. Dr. Sean Kane 01:18 So one of the advantages of having an inhaled version, as opposed to a tablet, is that we get local effect, and we can minimize the adverse effect profile of that drug. So we see this a lot with our inhaled corticosteroids, for example, where we get a lot of concentration to the lung and not a lot to other places of the body. Speaker 3 01:34 So how true is that phrase local delivery? Dr. Kane, so Dr. Sean Kane 01:39 it is local to the lung tissue, but you do get a little bit of systemic absorption of the drug, so you can see some systemic side effects. Speaker 4 01:46 Pharmacists are really the key players that are going to help you use these inhalers. No other healthcare provider really takes the time to really learn the use of spacers and the inhalers themselves. And there's several inhalers, and they come in many shapes and sizes. Speaker 3 02:02 And if you know your patient is on certain brand of inhaler, they can go on their website. Usually these manufacturer post videos of how to utilize this inhalers and devices. Dr. Sean Kane 02:11 So the first drug that we're going to be talking about today is albuterol, and it has three different brand names, ProAir HFA, Ventolin HFA, and Proventil HFA. So Dr. Michener, how do these work? Speaker 4 02:23 So they work on the beta two receptor, which is located in the lungs, and they're agonizing it, so they're acting on it and stimulating that receptor to open up the lung. Dr. Sean Kane 02:33 So did you say beta two receptor, beta two? So how can I remember beta one versus beta two receptors, Speaker 4 02:40 one, heart, beta one, two lungs, beta two. So Dr. Patel, how Unknown Speaker 02:43 is albuterol formulated? The Speaker 3 02:45 albuterol is available in various formulation, metered dose inhaler, oral solution. There is nebulizer solution, regular as well as extended release tablets and IV solution. Dr. Sean Kane 02:57 So although we have a number of different formulations, clinically, we really only use nebulized solution and the metered dose inhaler. Speaker 3 03:04 Is that correct? That is correct. Those are the most commonly used formulations. So what Dr. Sean Kane 03:09 kind of adverse effects might we see from albuterol? Speaker 4 03:11 So adverse effects might include anxiety or jitters, and some some patients may experience arrhythmias, although studies haven't shown that they have been clinically significant enough to necessarily stop the albuterol Dr. Sean Kane 03:25 and in the ICU sometimes albuterol can be used in patients who have hyperkalemia or a high potassium level. The reason for that is that stimulation of the beta receptor with albuterol can drive potassium into the cells and out of the blood. So Dr. Patel, what are some important patient counseling points with albuterol or ProAir, Ventolin and Proventil. Speaker 3 03:45 So even though we mentioned that MDI and nebulizer solution are the most commonly used, the MDI still taps the nebulizer solution. So when your patient is getting the MDI inhaler, make sure you ask the patients to shake the canister really well before using they also need to clean or wash the mouthpiece between each use. And if they're using the new box of inhaler, or they haven't used the inhaler for more than two weeks, it's important for them to prime it, so just two quick sprays in the air will prime the inhaler, and patient will make sure that they're getting the medication. And a very important thing to explain patient that this medication is quick acting, so when they have short up breath, this is going to come to their rescue, and that's why this is a rescue inhaler. Dr. Sean Kane 04:30 So this isn't necessarily an inhaler that a patient would use to control their asthma. It's something that they would use when they're having problems breathing. Is that right? That is very correct. Dr. King, so moving on to our next agent, leave albuterol. The brand name is zopon x. Now this sounds an awful lot like albuterol. Speaker 4 04:46 It sure is. It's the same chemical structure, but it is the active isomer of albuterol. Dr. Sean Kane 04:52 So why would someone choose leave albuterol instead of albuterol? Speaker 3 04:57 I have the same question Dr. Kane, because if I remember. Correctly leave albuterol is more expensive than albuterol. What do you have to say? Dr. Michener, Speaker 4 05:05 well, I can tell you that when leave albuterol was released, it also comes in NEBS in addition to the inhaler, all of the physicians basically stopped prescribing albuterol and they in any patient, they just started to use leave albuterol, saying that that patients across the board would have less tachycardia, when, in fact, if you look at the studies, there is some decreased tachycardia. But really, when studies were were done, it has similar efficacy to that of albuterol. And really the cost is certainly different, but the only subset of patients that they were able to show a significant difference was in pediatric patients. Dr. Sean Kane 05:48 And Dr. Michener, if I recall, the significant difference was only a couple beats per minute of heart rate. Is that correct? Speaker 4 05:53 That's correct. So it's really not that significant, but certainly in your wallet, it's much more significant. Dr. Sean Kane 05:59 And I'll bet that the clinical studies didn't take into account the tachycardia at the drug counter when they saw the price test. All right, moving on to our next agent is ipratropium, brand name Atrovent. Dr. Patel, how does Atrovent or ipratropium work? Speaker 3 06:11 So ipratropium is an anticholinergic agent. It basically blocks the action of acetylcholine at parasympathetic sites and the bronchial smooth muscles, and eventually this leads to bronchodilation. However, one thing to keep in mind, this is a short or rapid acting agent, so Dr. Sean Kane 06:30 instead of working at the beta two receptor, it's an anticholinergic. That is correct. So when do we see ipratropium used? Speaker 4 06:37 Usually it's used for COPD or bronchitis are in use for emphysema, and we'll learn a little bit later that it's also used in combination with other products, Dr. Sean Kane 06:49 and it comes as a metered dose inhaler and a nebulizer solution and even a nasal spray, but the nasal spray is for rhinitis, as opposed to asthma or COPD. So because it's an anticholinergic, we could probably predicts some of the adverse effects that we would see from ipratropium or Atrovent. Speaker 3 07:04 Yes, we definitely see some of the anticholinergic type side effects. The good thing about is that it is an inhale agent, so as we talked earlier, it doesn't have much systemic absorption. However, the side effects can include headache, dizziness, blurry vision, dry mouth, unpleasant taste. So one important point to talk to your patient is to avoid direct eye contact with this medication and going along the same line, ask your patient to wash their hands before and after each use. Dr. Sean Kane 07:35 And I've never used ipratropium, but I've definitely heard that one of the most common adverse effects is the dry mouth. If you think about it, you're squirting this anticholinergic right into your mouth. So you'd expect to have some of those local effects of the ipratropium, or Atrovent. Moving on to our next medication, it's really the uncle of ipratropium. The generic name is tiotropium. Brand name is Spiriva. So tiotropium, or Spiriva, is a long acting version of ipratropium. So it's a long acting anticholinergic that's taken once a day. Speaker 4 08:04 It has a very unique mechanism of delivery in that actually get patients get confused by in that it comes as inhalation capsules that you then place into an inhaler. So you have to tell them not to put the capsules in their mouth for just taking orally. Dr. Sean Kane 08:21 So you said it's an inhalation capsule, so you don't swallow it. Correct. You put it in an inhaler, Speaker 4 08:26 and so the inhaler punctures the capsule and releases the active agent into the person's lung. Dr. Sean Kane 08:33 So Dr. Patel, do we see any different adverse effects with tiotropium or Spiriva that we did or did not see with ipratropium or Speaker 3 08:40 Atrovent the adverse effect profile is similar to ipratropium. So as Dr. Sean Kane 08:44 far as patient education, we would probably want to also wash our hands, not touch your eyes after use, and educate the patient that they could have a lot of dry mouth with this medication. Speaker 3 08:55 And another important point to drive home is, unlike ipratropium, this is a longer acting agent. So this would act as the controller medication, or the maintenance medication. Versus ipratropium is a short and rapid acting because that will be a rescue inhaler. Dr. Sean Kane 09:10 So our next medication is a combination of the two medications that we previously talked about, albuterol and ipratropium as a combination product. The brand name is Combivent or DuoNeb. So Dr. Michener, when do we see Combivent or DuoNeb used in the hospital setting, Speaker 4 09:26 usually to control COPD and and you do see it about every four to six hours, generally in the NEB form. Or they might, when the patient is able to use the inhaler, well they they'll switch to the Combivent metered dose inhaler. Dr. Sean Kane 09:44 So I love clever brand names, and these two are probably one of my favorite brand names. So Combivent is a metered dose inhaler, and it's combo, combination product of albuterol and ipratropium, and vent like vent your lungs. The same is true with. Nebulizer form or DuoNeb duo, two products, Neb nebulizer. So now you can remember which one is the nebulizer, which one is the metered dose inhaler. That is very cool. Dr. King, so before we move on, I wanted to mention one very interesting warning with albuterol, ipratropium combination with DuoNeb or Combivent, and that said, it shouldn't be used in patients who have an allergy to soy or peanuts. This is interesting because the individual products don't have this warning, but the combination product does. Speaker 4 10:28 So when do you think you use DuoNeb versus albuterol? So Dr. Sean Kane 10:32 at least in the hospital, in patients who have a lot of respiratory distress, we want to give them as many different types of mechanisms to cause bronchodilation, so we have the anticholinergic effect of ipratropium, and we have the beta two agonism effect of albuterol. And also on the outpatient setting in patients who have more severe COPD, we would see the combination product used more often than just the individual products alone. So moving on to our next agent. The generic name is Fluticasone. The brand name is Flovent or Flonase, Speaker 3 11:02 and this is a whole nother category of medication which falls under inhaled corticosteroids. The way this medication works is it reduces inflammation by reduce reducing production of inflammatory mediators, and this creates widening of the airways or air sacs and reduces the spasm, that is, that occurs in response to the allergens. Dr. Sean Kane 11:26 Interesting, so I bet this works pretty quickly in patients who are having respiratory distress. Speaker 3 11:31 That is not true. Dr. Kane, this medication is actually a controller medication. So what you want to tell your patient is that this medication is going to work over the time. Unlike albuterol or ipratropium, which is short or rapid Dr. Sean Kane 11:44 acting, why would we have a patient on inhaled Fluticasone or Flovent? Speaker 4 11:48 Really, it's over the long haul to control their asthma, Dr. Sean Kane 11:52 and also, especially in patients with very severe COPD. It's somewhat of a controversial topic, but it can also be used in COPD as well. So what kind of adverse effects do we see with Fluticasone or Flovent? Speaker 4 12:04 One of the things that you see is thrush or candidiasis. It's an infection, a super infection, I guess you'd call it in the mouth, where there's an overgrowth of Candida, which is fungus. And so you need to have patients rinse their mouth with water and gargle and spit after each use. A lot of patients on the nasal spray report having nosebleeds as well. Dr. Sean Kane 12:24 One important counseling point that I tell patients is that they should be using their Fluticasone inhaler before they brush their teeth. Hopefully they're brushing their teeth twice a day, so they're also washing their mouth out twice a day after they use the Fluticasone inhaler. So the next medication is mometasone, and it has a couple different brand names. The nasal spray is Nasonex, and the inhaled form is Asmanex. Speaker 3 12:47 So it's another either nasal or oral corticosteroid, and the mechanism of action is similar to Fluticasone, as we discussed. Dr. Sean Kane 12:55 So really, this has the same adverse effect profile. It's used in the same type of patient population, so its use is very similar to that of Fluticasone or Flovent. The next agent is Fluticasone in combination with Salmeterol. The brand name is Advair. So what is Salmeterol? Dr. Kane? So Salmeterol is a long acting beta agonist which is similar to albuterol, except it lasts for 12 hours instead of four to six hours. And Advair is interesting because it comes as two different types of products. We see it as a metered dose inhaler, less commonly, but more commonly. We see it as a dry powder inhaler, which looks like a purple disc, which is why we call it a Diskus. Speaker 4 13:32 So how is that different from a regular inhaler? Dr. Sean Kane 13:35 So the Advair Diskus is a dry powder inhaler, so the patient actuates the inhaler, puts their mouth on it and inhales, and as soon as they inhale, the dry powder enters their lungs and has its effect. So as far as the adverse effect profile, we could probably anticipate what kinds of adverse effects we would see with Advair or Fluticasone Salmeterol, because we've already discussed many of these agents already. Speaker 3 13:57 So some of the side effects are similar to albuterol. We talked about tachycardia, palpitations, jitters or tremors and hypertension. On top of it, the Fluticasone is the inhaled corticosteroid. So remember the long discussion about oral thrush, and also explain your patient to wash their mouth after every single time they use Advair Dr. Sean Kane 14:17 so as we discussed, it does come as a metered dose inhaler, but we more commonly see the purple Advair Diskus. The Diskus actually comes with three different colored labels that correspond to three different types of doses. So just like a stoplight, we have a green, yellow and red. Green is the lowest dose, so it's for the least severe asthma. Yellow is the medium dose, which is probably the most common formulation that we see. Then finally, we have a red label represents the highest dose. When I say low, medium and high, I'm talking about the inhaled corticosteroid dose, whereas the Salmeterol has the same amount in each of the formulations. So because we have two drugs in this combination, it sounds like it would be a pretty potent. Drug for patients who are having an acute asthma exacerbation is that the case? Speaker 3 15:04 No, again, you're wrong. Dr. Kane, this medication is not intended for rescue use. This is a controller medication Dr. Sean Kane 15:11 only, so whether or not the patient has symptoms of shortness of breath, they should be taking this all the time so that they don't have shortness of breath in the future everyday. BID. So the next medication is very similar. The generic is formoterol combined with budesonide under a brand name of Symbicort. Speaker 4 15:28 So this is a long acting beta agonist and inhaled corticosteroid combination for use both in asthma and COPD. The formoterol being the long acting beta agonists and the budesonide, which is an inhaled corticosteroid, the Speaker 3 15:45 the combination product, which is Symbicort, is only available in the MDI, so Dr. Sean Kane 15:50 the HFA style inhaler. So we don't have any Diskus with this formulation, no Diskus, unfortunately, so many patients believe that when they're prescribed the steroid, that it's going to cause their muscles to get really big and that they'll be stronger. Is that the case? Speaker 4 16:02 No, I don't think that you can expect to be doing the next Tour de France, and that's really because the inhaled corticosteroids don't aren't androgenic that is that they don't work in the same way, through the same mechanism, as an androgenic steroid. Dr. Sean Kane 16:17 Well, that concludes week 10 of this Rosalind Franklin University, top 200 drugs podcast. I'm your co host, Dr. King, Dr. Mitchener, Unknown Speaker 16:24 and I'm Dr. Patel. Remember to study hard. Speaker 1 16:30 This has been an educational production by the Rosalind Franklin University, College of Pharmacy. The music for this podcast is an excerpt of Metro Mix by seesaw, released under Creative Commons. You.